FOOTNOTES:
[5] Memoir of Sir James Y. Simpson, by J. Duns. Edinburgh, 1873.
[6] Scotsman, May 9, 1870.
[7] Researches, Chemical and Philosophical, chiefly concerning Nitrous Oxide and its Respiration. By Humphry Davy. London, 1800.
[8] Lancet, 1870, History of Anæsthetic Discovery.
[CHAPTER XVI.]
SIR SPENCER WELLS AND OVARIOTOMY.
Thomas Spencer Wells, whose career in the revival of the operation of ovariotomy has attracted very widespread attention and interest, was born in 1818, being the eldest son of Mr. William Wells of St. Alban’s, Herts.
Without being formally apprenticed, he enjoyed many of the advantages of the old apprenticeship system, under an able country practitioner, Michael Thomas Sadler, of Barnsley, Yorkshire. Subsequently he spent a year with a parish doctor in Leeds, attending the Leeds Infirmary, and Hey’s and Teale’s lectures. The session 1837-8 was passed in Dublin, and there Graves and Stokes largely influenced the young surgeon. Continuing his course of culture in varied fields, he went to St. Thomas’s, London, and was a zealous pupil of J. H. Green, Travers, and Tyrrell. Here he obtained a prize for the best reports of post mortem examinations. Becoming a member of the College of Surgeons in 1841, he entered the navy as assistant-surgeon, and spent six years in the Naval Hospital at Malta.
In 1853 Sir Spencer Wells settled in practice in London, and in 1854 became attached to the Samaritan Hospital, then a dispensary for the diseases of women. At this time Sir Spencer states he knew less of this branch of the profession than of any other. In his younger days he had attended an unusual number of midwifery cases, but latterly his practice had been almost exclusively surgical, with a strong tendency towards ophthalmic surgery. It was at this time that he first became interested in the subject that has made his name so widely known.
From time immemorial the ovaries of women have been subject to diseased growths and fluid accumulations, for which there was scarcely a remedy, except when fluid could be drawn off through one or more punctures, and fatal results were the almost inevitable sequel of these diseases. Towards the end of the seventeenth and beginning of the eighteenth centuries, several medical men proposed to remove the diseased organ by an incision in the front wall of the abdomen. William Hunter in 1762 put forward a method by which this operation, otherwise full of danger, might be rendered feasible; and John Hunter, lecturing in 1785, favoured the idea of removal, considering that the opening would not necessarily constitute a highly dangerous wound. In 1798 Chambon, in a book on diseases of women, published at Paris, strongly argued in favour of the operation. Although it does not appear that he ever himself performed it, he says, “I am convinced that a time will come when this operation will be considered practicable in more cases than I have enumerated, and that the objections against its performance will cease.” John Bell also has a share of credit in this matter, for in his lectures on surgery at Edinburgh in 1794 he dwelt with much force on the practicability of removing ovarian tumours by operation. It was reserved, however, for a pupil of his, Ephraim M’Dowell, from Virginia, to perform the first modern operation of ovariotomy for disease. He settled in practice in Kentucky in 1795, and in 1809 carried into effect this novel operation upon a middle-aged woman, who survived to complete her seventy-eighth year in 1841. Thus an American had the glory of first boldly starting in the new path.
It was difficult to give the new operation a start in England. “It must be remembered,” says Sir Spencer Wells, “that, at that time of day, the mortality from all operations was much greater than it is now; that the sick and diseased were more passively quiescent under their maladies and less tolerant of any surgical suggestions, just as we ourselves find to be the case among the unroused population of an outlying agricultural district; that they were not buoyed up, as modern women are, by the histories and promises of painless extirpations under chloroform or methylene; and that, without any mawkish sentimentalism, surgeons themselves had to encounter the peine forte et dure of their suppressed sympathy, and nerve themselves up to the infliction of the most deliberate and tedious eviscerative vivisection. The disease was looked upon as a mystery, and its ending in death as a matter of course; and, instead of being accompanied, as we now see it, by fretful resistance and chafings to escape, it only led to stolid endurance or religious submission; and on the part of the profession, to pity and endeavours to alleviate the inevitable misery. But M’Dowell was a free man, in a new country, clear from the conventional trammels of old-world practice, found his patients in the most favourable conditions of animal life, seems to have had one of those incomprehensible runs of luck upon which a man’s fate and reputation so often turn if he has the sagacity and energy to put such fortunate accidents to good account, and was happy, as those usually are who can afford or constrain themselves to wait, in finding suitable time, place, persons, and opportunity for working into fact the notions of his tutor, Bell. He lost only the last of his first five cases of ovariotomy, and thus, as it were, established at the outset what until recently was complacently regarded as a satisfactory standard of mortality for so serious an operation.”[9]
As a surgeon M’Dowell was “cautious, calm, and firm, paying great attention to the details of his operations and treatment, and selecting and drilling his assistants with great care.” In 1879 a granite obelisk was raised to his memory in the cemetery where he was buried, near his home, in commemoration of his courageous and important work.
Long after M’Dowell’s operations became known, a case was discovered as far back as August 1701, in which Robert Houstoun, a Glasgow surgeon, operated on a woman for a large tumour in a fashion somewhat anticipatory of modern ovariotomy. She recovered, and lived sixteen years afterwards. So often are anticipations of great improvements to be found, that it appears that the merit, like the difficulty of actually making a thing practicable and practised, is as great as, or greater than, that of discovery.
Several American surgeons followed M’Dowell, but the operation did not come rapidly into vogue, partly because anæsthetics had not yet been introduced. Lizars of Edinburgh had one successful and one unsuccessful case in 1825. Dr. Granville attempted it in London in 1827, but the operation was abandoned on account of the difficulties met with: fortunately the patient recovered. In 1836 Dr. Jeaffreson of Framlingham first operated successfully by means of the short incision recommended by William Hunter; the patient recovered and bore a family afterwards. In the same year several other provincial surgeons were equally successful. In 1840 Mr. Benjamin Phillips operated unsuccessfully at the Marylebone Infirmary. In 1842 Dr. Charles Clay of Manchester commenced a long series of operations, operating four times in the year, three times successfully. The first successful case in London was by Mr. Walne in November 1842. From this time operations were not infrequent. In September 1846 Mr. Cæsar Hawkins proved for the first time that success was possible in a London hospital; his precautions and his directions were most excellent. In June 1848 Dr. Charles Clay published a series of 32 cases with only 10 deaths, and he continued to operate for many years until he had performed 395 operations with only 101 deaths, slightly above 25 per cent. He used long ligatures. In 1850 Mr. Duffin, in London, employed an important improvement in procedure.
Sir Spencer Wells’s medical education and study in all these years had not led to his paying any attention to the subject. It was evidently outside the prevailing ideas of most of the medical schools. His opinion in 1848 was certainly against the justifiability of the operation. In 1853 or 1854 he became acquainted with Mr. Baker Brown, and in the latter year assisted him at the Middlesex Hospital in his eighth case of ovariotomy. This was the first time he had seen the operation attempted, but the patient died. Several unsuccessful cases led Brown to give up his attempts entirely from March 1856 to October 1858.
When the Crimean War broke out, Sir Spencer Wells betook himself to the army in the East. There he learnt much of the freedom with which the abdomen might be injured and yet recovery take place if the constitution was good and other things were favourable. He saw frightful cases of laceration by fragments of shell recover after careful cleansing and accurate closure of the wounds. He returned to London much less afraid than before of abdominal wounds. Renewing his work at the Samaritan Hospital, he at first saw very little of ovarian disease, and it was not till December 1857 that he made his first attempt to perform ovariotomy, which, however, on Baker Brown’s advice, he did not carry to completion. His second attempt was completed, with Brown’s assistance; but the latter did not recommence to operate himself until after an interval of more than two years and a half.
Sir Spencer Wells has given a graphic account of his early experiences.[10] “It would be difficult to imagine,” he says, “a position more disheartening than that in which I was placed when making my first trials of ovariotomy. The first attempt, as I have said, was a complete failure, and strengthened not only in the minds of others, but in my own mind, the fear that I might be entering upon a path which would lead rather to an unenviable notoriety than to a sound professional reputation. And if I had not seen increasing numbers of poor women hopelessly suffering, almost longing for death, anxious for relief at any risk, I should probably have acquiesced in the general conviction—have been content with palliative tapping, or making some further trials of incision and drainage, or of iodine-injection, or of pressure, rather than have hazarded anything more in the way of ovariotomy. It may be forgotten now, but it is true, that at that time everything was against the venture. The medical press had denounced the operation, both in principle and practice, in the strongest terms. At the medical societies the speakers of the highest authority had condemned it most emphatically. The example of the men who had practised it was not followed; some of them had given it up. Only once had a successful result been obtained in any of our large metropolitan hospitals, that by Cæsar Hawkins, at St. George’s Hospital, in 1846, and he never undertook it a second time. Every other attempt—at Guy’s Hospital by Morgan, Key, and Bransby Cooper, at St. Thomas’s by Solly—had ended in death.” In 1858 three cases were undertaken, and all with success, which did much to confirm Mr. Wells in his new practice. The fourth he lost, and to explain the cause he made some experiments upon animals, which led to important improvements in methods, yet during 1859 five out of eleven operations had fatal results.
The translation in 1860, by Mr. John Clay of Birmingham, of Kiwisch’s “Diseases of the Ovaries,” with its valuable tables showing the results of all recorded cases, was of great importance to the progress of ovariotomy. Since then vast improvements have been introduced, the mistakes of earlier operators corrected, bichloride of methylene has been used with gratifying results instead of chloroform, precautions have been taken to prevent the access of any taint of infectious disease, every medical man present at the operation has been put under strict inquiry as to his not having recently been in a dissecting or post mortem room, and the utmost possible purification of house, room, bedding, clothing, and instruments has been practised. Indeed some precautions have been so stringently insisted on as to give considerable offence at times. The old vegetable material for ligatures and sutures, coarse whipcord or twine, has been given up, and after many trials of metallic wires pure silk has been settled upon as the most trustworthy. In fact it is entirely absorbed without needing to be pulled out again. The multitude of intricate details involved precludes our giving an account of the stages by which the present perfection has been reached. In 1864 Mr. Wells, in pursuance of a pledge he had given to record and publish his entire experience, favourable and unfavourable, published a full account of his first 114 cases. Since then two extended records, one in 1872 giving an account of 500 cases, and a second in 1882 with 1071 cases, have been published. The most remarkable thing in the history is the gradual diminution in mortality. In the first hundred cases the deaths were thirty-four; in the last they diminished to eleven; in the seventy-one cases following the first thousand only four died, while sixty-seven recovered. This is notwithstanding the fact that Sir Spencer Wells is often called upon to treat patients rejected by other surgeons as unfavourable cases. A recent record by Thomas Keith, an Aberdeen surgeon, in which a mortality of only three and a half per cent. has occurred, even outdoes this astonishing result. It is needless to relate how the operation has been adopted by most Continental surgeons of mark, and with excellent results.
We may note that already in 1864 Mr. Wells had treated of hospital atmosphere, organic germs as causes of excessive mortality, and commented on the researches of Polli with sulphur and the sulphites, before as yet the antiseptic treatment had come prominently forward. When Mr. Lister’s system became established, Mr. Wells gladly adopted all its essentials in his operations—the spray, carbolised sponges, instruments, &c. He is convinced that by these precautions those patients who have recovered have suffered much less from fever, while convalescence has been more rapid than it used to be. In fact, the general result of the ovariotomy of the past twenty-five years is “thousands of perishing women have been rescued from death; many more thousands of years of human life, health, enjoyment, and usefulness have been given to the race, and to all future victims of a malady before inevitable in its fatality, consolation, hope, and almost certainty of cure.”
The good influence of this success has, Sir James Paget says, extended to every department of operative surgery, and will always continue to be felt. It has led to an extension of the whole domain of peritoneal surgery, leading surgeons to attempt and persevere until successful in many operations formerly considered quite out of reach.
Sir Spencer Wells is by no means content with promoting the progress of operative surgery; he looks forward to prevention with the greatest hope, and advocates measures calculated to promote accurate research in pathology. He is a strong supporter of any possible action by the College of Surgeons in this direction. He says: “While we modern surgeons congratulate our science on its liberation from the trammels of tradition; upon its working in an atmosphere cleared of the mist of superstition; upon the changing of its mode of action from a blind grappling with the phantom entities of a disease to a study and manipulation of overnourished or degenerating tissues; upon its having laws which can be understood and rules of practice which can be followed, we ought not to overlook one fact, which perhaps is more evident to outsiders than to ourselves, standing as we do in the dust and turmoil of the arena of our work. I mean that that work, good and useful as it is, has too much the character of what is technically called ‘salvaging’—is too much in correlation with what is done by the lifeboat service.”
Mr. Wells had long been a member of the Council of the College of Surgeons when in 1882-3 he became its President. In 1882 he was created a baronet. He has by no means limited himself to questions of operative surgery. His public efforts have been frequently directed towards important subjects of state and municipal polity, sanitary matters, the abatement of the smoke nuisance, the securing of the health of passengers on board ship, the hygienic condition of hospitals, and perhaps most important of all, the mode of disposal of the dead. His views on the evils of the present system are well set forth in a letter he addressed to the Times on March 3, 1885, from which we make the following extract:—
“In this metropolitan district in the twenty-five years 1859-1883, the deaths registered number 1,896,314. Of course, the dead have been buried, and with scarcely an exception, in and around London. Grant that in ten years a body may become harmless—although I do not at all believe that it does so within twenty years in our soil and climate—can any imagination conceive the enormous mass of decaying animal matter by which we are surrounded? Could any one be surprised at the outbreak of some devastating pestilence a hundredfold more destructive than the plague or black death of the Middle Ages? And ought not every sanitary reformer to aid the revival of the ancient practice which would convert the existing cemeteries, so rapidly becoming sources of danger to the public health, into permanently beautiful gardens, receptacles for vases and cinerary urns, which would encourage sculpture, mural decoration, and coloured glass-work; while in our country churches the ashes of the people might again repose in death near the scene of their work in life perfectly harmless, instead of polluting the earth of the church-yard and the water drunk by the surviving people, or being carried far from their homes and places of worship to some distant cemetery, which before long must become overcrowded and pestilential. Public sentiment may for a time revolt at an innovation, but a very little reflection will bring most people to agree with part of the Bishop of Manchester’s address on consecrating a new cemetery. He said:—
“‘Here is another hundred acres of land withdrawn from the food-producing area of the country for ever.... In the same sense in which the “Sabbath was made for man, and not man for the Sabbath,” I hold that the earth was made, not for the dead, but for the living. No intelligent faith can suppose that any Christian doctrine is affected by the manner in which, or the time in which, this mortal body of ours crumbles into dust.’”
Sir Spencer Wells in his frequent communications on the subject lays much stress on the fact that such undoubted proofs of natural death are required by the Cremation Society before cremating a body that no murderer or poisoner would think of getting the forms filled up. At the Milan Crematorium a death from poison was actually discovered in this way, when natural death only was believed to have taken place.